When the Trauma's Over

A psychotherapist and PTSD expert explains how people revisit horrific events -- and how they can be guided away from them.

In seconds your world is going to end -- you're convinced of it. You're flooded with feelings of helplessness, incredible terror, and a loss of control, catalyzed by this sense of destruction. The moment arrives and ... somehow you survive.

It's this kind of event -- one in which your sense of self becomes completely unglued -- that can cause Post Traumatic Stress Disorder (PTSD). Belleruth Naparstek, a psychotherapist and an expert in the therapeutic use of guided imagery, explains in her new book, Invisible Heroes: Survivors of Trauma and How They Heal, how these extremely traumatic events and their victims vary widely. It could be soldier under heavy enemy fire, a child trapped alone during a hurricane, or a man in a doctor's office who has just found out his wife has terminal cancer. And although PTSD can be the result of one traumatic event, more often it occurs from compounded effects of numerous events, as would be the case with a person who is sexually abused repeatedly. The common thread in all of these abject scenarios is that the person loses trust in their world because it has, as Naparstek writes, "broken its promise, revealing itself to be capable of devastating chaos and cruelty."

In a recent phone interview, Naparstek discussed the psychological and biological consequences of PTSD as well as her use of guided imagery to alleviate its incapacitating effect.

Q: What is PTSD and how is it different from a normal reaction to trauma?

A: Very often a normal reaction to this kind of horrific trauma is acute stress syndrome, and the difference is that the syndrome is transient and it goes away. In Post Traumatic Stress Disorder, the symptoms are more severe, but more critically, not only do they last but also sometimes they'll surface much later and intensify over time. It's a group of symptoms that, because they're biochemically and neurophysiologically based, feed themselves. It's basically starting out to be a regular response to a terrifying event, where the person is experiencing a sense of impending annihilation by overwhelming force. Normally, in three to six months the symptoms will go away. In PTSD the symptoms stick around, they get worse, and they take on a life of their own.

Q: What are the physiological changes that take place during acute trauma, and why do they continue in PTSD?

A: It's a natural built-in response to a threat to life that the body just gets blasted with alarm biochemicals. When the threat has passed, there is a natural settling down that the body knows to do as well, so that eventually people go back to some sort of homeostatic balance. Now, this can take a while -- sometimes months -- but the balance normally occurs. In PTSD, the body keeps swinging back and forth between this very adrenergized alarm stage and then a vegetative state trying to settle itself down. What happens whenever there is a symptom like a flashback or a nightmare, the body repeats this reaction. It's like being there again -- the body reacts in exactly the same way. It becomes, in some people, this closed feedback loop that keeps feeding itself.

Q: What kind of emotional changes take place in PTSD?

A: They really are brutal. People experience intense extremes of terror and fury. It's not at levels that most people are used to negotiating. Tremendous fearfulness, anxiety and phobias will start coming up with some being afraid to leave their house or even their bedroom. There is great grief over all the things that have been lost, including just being able to take life for granted -- that the sky isn't going to fall in when you walk out the door. There is also this pervasive sense of isolation and loneliness. You are not like normal humans who are having normal lives. Even if a person sort of logically knows better, it doesn't matter.

Q: Is how a person reacts to a horrific event or events indicative of whether or not they'll suffer from PTSD?

A: Yes, but it's hard to say what comes first, the chicken or the egg. For instance, if a person is very proactive and resourceful and responds in a very functional way to this threat, they're less vulnerable to PTSD. But, that could be because of the very fact that they can respond. In other words, the person who freezes, dissociates and goes into this almost enforced vegetative state where they can't move, that's the person who is most likely to get PTSD. And that might be just a biochemical precondition that causes them to freeze, and that would in fact make them less resourceful.

Q: In the book, you describe dissociation as a blessing and a curse for those who experience it during a traumatic event. Why?

A: Simply because of the fact that if someone dissociates -- if they have this sort of out-of-body disconnected observing of themselves from a distance -- they are more likely to go on to develop PTSD, and that's not a good thing. On the other hand, the good thing is that it allows them to psychically escape from events that they are physically unable to escape from. And because they're good dissociators, they're very good at responding to these immersive right-brained therapy techniques that I discuss in the book.

Q: Are there other traits that predispose people for PTSD? What about its prevention?

A: For starters, women and children are more predisposed, and this is true around the planet, regardless of socio-economic status. They are about twice as much vulnerable as men, and some studies have it as high as six times more vulnerable. This might seem obvious, but people with histories of psychological difficulty are also more likely to get PTSD. Funny, but people who are drunk during the event are pretty much inoculated from PTSD. It's the only positive advertisement for getting loaded, because studies, especially those of nightclub fires, have shown that to be the case. There's something about alcohol that interrupts the biochemical cycle.

Q: What about treatment? Why is it that PTSD patients don't usually respond well to talk-oriented, language-based therapy?

A: In most therapy you are sitting down with a sympathetic person, so you can step back, look at your experience and get some real healing by just getting a different view. With PTSD, the biochemical flooding that I mentioned earlier actually shuts down language centers and heightens the more primitive parts of the brain and their functions. These heightened functions are in the mid-brain and brain stem where people experience body sensations, emotion, awareness, perception, kinetic movement, that are all related to instant survival. Normally, you could talk your head off and think away, but when it comes to the specifics of what has happened in PTSD, many people are unable to speak. Since these memories aren't stored in the regular places, they can't access them. Therefore, when a talk therapist, which is most of us, tries to get someone to talk about this, they can actually trip a wire where a person experiences a flashback, retraumatizing a patient.

Q: As an alternative to talk-based therapy, you advocate guided imagery. What is it?

A: It's basically deliberate directed daydreaming. You're guided to use your imagination -- all of the things that are hyper-acute in a traumatized brain. You're using images, body sensation and perception. Since people can't usually talk about it, the therapist is making an end run around the cognitive, linguistic parts of the brain to help the person. This can be as simple as teaching a traumatized police officer to stand on his corner and imagine his favorite place in all of its multi-sensory glory. This will help settle him down when he feels a wave of adrenergized panic hormones coming up. It balances the hormones: if they're low, it will bring them back up, and if they're high, it will bring them back down. It brings the body back into balance.

Q: Is there some point in guided imagery therapy that a patient goes beyond simply soothing themselves?

A: There is some very intense imagery, but I don't recommend it to people immediately following a trauma. As a matter of fact, the Red Cross made the mistake of handing my healing trauma imagery tapes out at Ground Zero, and a lot of people weren't ready for them yet. They're very evocative and should be used only after people are good at self-regulating and are ready to move on to de-numbing. You want to learn how to relax at will and handle your symptoms -- you can't do anything until you feel safe enough to know you can step back from a feeling of panic. When you have this base line of skills and you're feeling like you're ready to move on -- for some it's a matter of days and weeks, and others it's a matter of months and years -- this imagery helps you get back in touch with your feelings. This is a mixed blessing. If a person's been numbed out, getting back in touch with some of these very intense feelings isn't exactly a day at the beach. We had a group of veterans at the Biloxi VA, and those guys did not like being de-numbed, but they said, almost to a man, that they would do it again and recommend it to their friends and combat colleagues.

Q: How long has PTSD been recognized as a disorder, and do you see it increasing?

A: Not long. It first appeared in the DSM (Diagnostic and Statistical Manual of Mental Disorders) in 1980. If we had it to do all over again, I would label it a syndrome and not a disorder. It's a syndrome; it's really not a disorder. It's an out of balance; it's a syndrome of things that happen from abnormal events, and it doesn't mean the person's abnormal. There's something about disorders that is defeatist even to start with. Yes, I see it increasing. It's hard to say why, but I think we're getting more and more natural disasters on the planet, and I don't think it's my imagination. Plus, there's urban crowding that breeds violence, and I'm not sure if there's more war, or just more people, but all of these conditions seem to be on the rise. Probably the biggest influence is population.